Malignant melanoma: current management.

Malignant melanoma is increasing in frequency and is becoming one of the leading causes of cancer death. Early recognition and treatment is often curative. Recognition includes the identification of malignant precursors, the dysplastic nevus. Prognosis for survival and disease is dependent upon tumor thickness, level of invasion, anatomic location, growth pattern, ulceration as well as age and sex. Adequate biopsy of suspicious lesions is critical to both diagnosis and prognosis. Wide excision is the treatment of choice, with margins determined by tumor thickness. The management of regional lymph nodes remains controversial. Radical lymphadenectomy is indicated for clinically suspect adenopathy and may improve survival. There does not appear to be significant benefit of elective lymph node dissection for melanomas less than 0.76 mm or greater than 4 mm in thickness. Intermediate lesions may be managed in one of two ways: through careful follow-up with node dissection performed if clinical change is evident; or ELND may be performed. Ongoing trials to determine the benefit of ELND are presently under way. Isolated limb perfusion may be a desirable option for adjuvant therapy in the treatment of extremity melanomas, especially in patients with high-risk lesions or with disease recurrence since improved survival may be achieved. The role of surgical intervention in the management of distant metastases is limited but may have a role in palliation.